The Final Journey

What's the relationship between heroin, end of life debates, and mental health?

Posted Sep 17, 2019

In 1979, a Toronto-based, Harvard-trained doctor and syndicated newspaper columnist, Kenneth Walker, initiated a campaign to legalize heroin for terminal cancer patients in Canada. A public figure and well-known doctor, Walker was better known as W. Gifford-Jones.

This year marks the 40th anniversary of his effort to raise awareness about opioids, pain, and proper end of life therapies. In doing so, he tackled stigma, mental health in palliative care, and outdated ways of thinking about drug policy. 

As Canadians (and Americans) deal with the ongoing opioid crisis and new medically assisted death policies in 2019, it is an auspicious moment to reflect on Walker’s struggle.

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Gifford-Jones declared in January 1979, that heroin ought to be added to the list of legitimate painkillers in Canada. While raising nearly a million dollars and producing greater public and political awareness, he encountered resistance in the form of the Canadian Cancer Society, Canadian Society of Hospital Pharmacists, and the Royal Canadian Mounted Police. 

Heroin/Wellcome Trust
Source: Heroin/Wellcome Trust

Law enforcement authorities suggested that legalization would pose a threat to Canadian citizens because heroin might leak into the Canadian streets. 

Medical experts argued that heroin was ineffective relative to other available opioids and that addiction was a consideration to be discussed; some other leading authorities in palliative care argued that the legalization effort detracted from more holistic approaches to pain.

Between 1983 and 1984, Walker heightened the rhetoric in his national column, ran full-page advertisements in newspapers like this one and leaned on friends in government. He published excerpts of letters from Canadians whose loved ones had died in excruciating pain, who suffered through anxiety, and he challenged the Palliative Care Foundation, which opposed heroin. 

In the Globe and Mail, one of Canada’s national newspapers, Walker criticized the Canadian Cancer Society’s opposition to his agenda.  During 1984, he stated boldly, “This Christmas, will the real hypocrites please stand up.” It was time to take stock of the best drug to address the multiple mental and physical associated with terminal pain.

He had already found some support by this time. In November 1983, an editorial in The Toronto Star announced: “Heroin represents the most effective way some cancer patients can manage the terrible pain that can come with the disease. It should…be available to them.” In June 1984, a Globe and Mail editorial attacked the government for “30 years of delay.” Heroin was “widely used in Britain where there are no political arguments against its medicinal use.”

Looking back, Walker’s story embodies how the policy-making surrounding pain, opioid use and misuse, and suitable end-of-life therapies offer continuing challenges in Canada. Embedded in his approach was a holistic approach to the psychological trauma involved in palliative care. And it reminds us that we should not shy away from evidence-informed innovation or tough questions. 

As Benedikt Fischer and his colleagues wrote in The Lancet recently, Canada has implemented and expanded syringe and naloxone distribution, opioid substitution treatment, and supervised consumption sites. But even more action is necessary. Meanwhile, according to Dr. Bonnie Henry, B.C.'s provincial health officer, turning the “corner on this complex crisis” will require ending the stigma associated with opioid misuse.

A strategy that appears both morally and medically bankrupt is the “forced tapering” of opioid use. In the US, even people with terminal cancer have been impacted by guidelines that reduce or end pain pill prescriptions. Maia Schlavitz has argued this type of cure is worse than the disease

By contrast, it’s commendable that $5.5 million dollars have been allocated for a palliative paramedic program to train thousands of front-line paramedics.

In 1984, Jake Epp, the new minister of health after the Conservative victory that year, sided with Walker. He announced in December that the government would legalize the use of heroin in cases of severe chronic pain or terminal illness.

As Epp put it, the issue was not a technical question “but rather the meaning of life and how death with dignity can be enhanced.” 

Walker was pleased with the outcome. Medical heroin was a way of dealing with cancer in a respectful manner, he argued, and insisted that the drug’s accessibility in clinical settings, however limited, epitomized a patient-centered approach.

Much like today, medical heroin in the early 1980s produced discord among the public and medical experts. The evidence base (or lack thereof) ran up against long-standing stigmas about heroin’s use inside and outside controlled settings. It prompted debates about the nature of addiction and personality

This was a historic moment that witnessed a redefinition of opioids in end-of-life care, but also a time when prescribing of strong opioids such as oxycodone began to increase dramatically in the US and Canada.

Forty years on from the start of the conversation about heroin in end of life settings, opioids continue to divide Canadians, whether the focus happens to be scientific knowledge, cultural assumptions, and social concerns. 

As Walker described in 1979, “political, not medical, decisions” characterized the way heroin and other opioids were handled. It was time, he insisted, that the medical community showed more leadership

This article is based on a previous publication in the Canadian Medical Association Journal.